Menorrhagia: prolonged or excessive bleeding occuring at regular intervals - heavy flow only.
Metrorrhagia: irregular bleeding only.
Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals.
Intermenstrual bleeding: bleeding of variable amount between regular menses.
Polymenorrhea: uterine bleeding occurring at regular intervals less than 21 days.
Oligomenorrhea: uterine bleeding occurring variably between 35 days to 6 months.
Amenorrhea: no uterine bleeding for at least 6 months.
Primary dysmenorrhea: menarche to 19 years. Severe menstrual cramps within 48 hrs of onset of menses. Normal abdominal and pelvic exam. Pain can continue 24 - 72 hrs.
Tx: NSAID +/- Oral contraceptives
Secondary dysmenorrhea: >20 years. Pelvic pathology. Pain progressive with age not always synchronized with menses.
**Endometriosis, PID, cervical stenosis, cervical polyps, ovarian cysts, leiomyomas/fibroids**
IUD complications, endometrial ca, imperforate hymen, uterine synechiae.
Labs: G&C, HIV, TSH, pap smear, endometrial bx, TVUS, urine hCG, Bleeding time.
PMS - Tx: NSAIDs 10 day prior and 2 days into menses + vit B6 + Prozac 20 mg PO daily.
I. Abnormal menstrual syndromes:
A. Chronic pain syndromes
1) Dysmenorrhea: painful menses
(a) Primary dysmenorrhea
(b) Secondary dysmenorrhea
2) PMS
B. Abnormal uterine bleeding d/o
II. Pathophysiology:
C. Normal hormonal changes in the menstrual cycle result in progressive differentiation of the arterioles of the uterine vasculature up to the premenstrual state. These changes also affect the innervation (cholinergic, adrenergic, and peptidergic) of the uterine arteries, regulating spontaneous contractile activity of the smooth muscle walls of the vessels, and affect their responses to different vasoactive substances like vasopressin, oxytocin, endothelin, and noradrenaline.
D. Primary dysmenorrhea is defined as menstrual pain with normal pelvic anatomy. There is an increase in secretion of vasopressin which acts on type VI vasopressin receptors of the uterus, causing myometrial hyperactivity and vasoconstriction with resultant uterine ischemia and pain. Primary dysmenorrhea have following characteristics:
1) Onset is from menarche to age 19 years
2) Onset of pain is typically 24 to 36 hours before the onset of menses and can continue 24 – 72 hours into the menses.
3) May occur due to increased prostaglandin activity (mostly PGI2) in the uterus, and an increased secretion of vasopressin resulting in increases uterine contractility.
E. Secondary dysmenorrhea is defined as menstrual pain with pelvic organ pathology. Common causes include: endometriosis, leiomyoma, endometrial CA, IUD, polyps of the cervix or uterus, PID, cervical stenosis, ovarian cysts, imperforate hymen, and uterine synechiae.
1) Onset is in women over 20 years of age.
2) Pain progresses with age.
3) Pain is not always synchronized with menses
III. DDx of Menstrual problems
F. Dysmenorrheas
1) Primary dsymenorrhea..... very common
2) Secondary dysmenorrhea
(a) Cervical stenosis................. common
(b) Cervical polyps................... common
(c) Ovarian cysts....................... common
(d) PID....................................... common
(e) Endometriosis..................... common
(f) Leiomyomas/fibroids.......... common
(g) IUD complications.......... uncommon
(h) Endometrial CA.............. uncommon
(i) Imperforate hymen..................... rare
(j) Uterine synechiae....................... rare
3) Premenstrual syndrome
(a) Major depressive and anxiety d/o............... common
(b) Dysmenorrhea............................................. common
(c) Mittelschmerz............................................. common
(d) Endometriosis......................................... uncommon
(e) Tubo-ovarian abscess......................................... rare
G. Abnormal uterine bleeding
1) Hormonal dysfunctional uterine bleeding........ common
2) Intrauterine pregnancy state............................. common
3) Spontaneous abortion........................................ common
4) Ectopic.......................................................... uncommon
5) Molar pregnancy....................................................... rare
6) Placenta previa, placenta abruptio........................... rare
7) Vaginitis............................................................ common
8) Cervicitis........................................................... common
9) PID..................................................................... common
10) Endometritis.................................................. uncommon
11) Vulvitis..................................................................... rare
12) Foreign body........................................... fairly common
13) Direct trauma................................................ uncommon
14) Thyroid disease....................................... fairly common
15) Coagulopathies......................................................... rare
16) Cervical neoplasia......................................... uncommon
17) Uterine neoplasia.......................................... uncommon
18) Ovarian, fallopian, vaginal, vulvar........................... rare
H. DDx: 80% of dysmenorrhea is primary dysmenorrhea. The DDx for secondary dysmenorrhea depends on the age of the patient, history, and PE. For example: a woman less than 30 years old who has dysmenorrhea and pelvic pain at the time of ovulation is likely to have endometriosis. In perimenopausal, menopausal, and postmenopausal women who have dysmenorrhea the pelvic pathology may be due to cervical stenosis, leiomyomas, or endometrial CA. Imperforate hymen in younger women who have not had any menses and present with severe pelvic pain and hematocolpos. PID must be considered in any woman who is sexually active and presents with pelvic pain with or without vaginal discharge.
IV. Clinical Evaluation: When evaluating a woman with dysmenorrhea, the hx should be guided by the woman’s age, sexual hx, and the timing of her menstrual cycle events with pelvic pain. Consider primary dysmenorrhea as the likely Dx in a woman who has moderate to severe menstrual cramps within 48 hours of the onset of her menses and has a normal abdominal and pelvic examination. However, if she is older than 20 years and her pelvic pain is not always synchronous with her menses, then secondary causes should be more aggressively explored.
V. The Dx of secondary dysmenorrhea is made when a woman with menstrual pain has pelvic pathology identified at the time of the physical examination, following appropriate laboratory studies, or at laproscopy. Moreover, in women with secondary dysmenorrhea, sx progress with age.
One of the most common causes of secondary dysmenorrhea is endometriosis. Following are factors associated with a higher risk for endometriosis in relative order of the strengths of their association:
§ Asian race,
§ Tampon use x 14 years
§ Long duration of IUD use
§ Heavy menstrual flow
§ Severe menstrual cramps
§ One live birth
§ Age over 30 years
§ Long cycle length and long duration of menstruation
History: The general approach to a patient with c/o dysmenorrhea involves:
Age
Duration and description of the pain and timing of the pain in relation to the menstrual cycle
Prior hx of dysmenorrhea
Prior Tx and response to Tx, prior prescribed and OTC medications for dysmenorrhea
Sexual hx
H/o past STDs, contraceptive use, endometriosis
Family hx of gynecologic cancers, gynecological surgeries or procedures.
Consider primary dysmenorrhea in a woman <20 years old, with onset of her pain 24 – 48 hours before menses, and absence of any abnormal pelvic pathology.
Pt >20 year old has severe dysmenorrhea that is particularly intense at the time of ovulation and her menses, consider dx of endometriosis and do w/u. If pt has associated back pain and diarrhea at the time of ovulation and menses consider the possibility of endometrial bowel implants.
If Pt has had multiple colposcopies for severe cervical dysplasia and has the cervix frozen multiple times, consider cervical stenosis.
If Pt is postmenopausal and has menometrorrhagia, endometrial CA must be ruled out first.
If Pt has fever, malaise, has hx of STDs: think PID or tubo-ovarian abscess.
If Pt has hx of gynecologic surgery: pelvic adhesions
Psychosocial hx assists in evaluation of the Pt’s perception of the problem, coping ability, and formulation of the treatment plan
XIV. Physical Examination: Abdominal exam to evaluate for enlarged uterus or large ovarian masses. Perform a complete pelvic examination, which includes a rectovaginal examination in order to evaluate the uterus and adnexal areas for size, masses, and areas of tenderness. Any abnormal pathology, precludes the Dx of primary dysmenorrhea.
§ Cervical motion tenderness, uterosacral tenderness and nodularity, limited uterine mobility or a fixed uterus: endometriosis
§ Palpable enlarged uterus: leiomyomas, pregnancy, malignancy
§ Cervical stenosis on speculum exam: cervical stenosis
§ Fever, abdominal pain or pelvic pain, thick purulent vaginal or cervical DC, and exquisitely tenderness on palpation of pelvic organs: cervicitis, PID, tubo-ovarian abscess.
§ Missed period, or abnormal previous period, with unilateral pelvic pain, vaginal bleeding, with adnexal fullness on pelvic exam: ectopic pregnancy, missed or threatened abortion
§ Any vaginal bleeding from cervical os in postmenopausal woman or intermenstrual bleeding in a perimenopausal woman, endometrium >4 mm thickness on transvaginal US, palpable pelvic mass, or endometrial cells on Pap smear: Uterine CA.
XV. Laboratory Tests: There is no need for any laboratory test for Dx of primary dysmenorrhea, as it a Dx based on accurate hx and PE. For secondary dysmenorrhea the choice of lab test are guided by the hx and PE findings.
§ Women with prior STDs, hx of vaginal or cervical DC, multiple partners and unprotected intercourse, and those with sx between 4 and 14 days: think STD, culture for gonorrhea and chlamydia, test for HIV
§ Postmenopausal women with heavy or irregular menstrual bleeding and premenopausal women over age 40 with chronic anovulatory cycles, obesity, HTN, DM, or long-term unopposed estrogens are at high risk of endometrial CA, and should receive endometrial Bx.
§ Pts with pain at the time of ovulation should get an US to evaluate the possiblity of endometriosis or ovarian cysts.
XVI. Management:
1) Primary Dysmenorrhea: NSAIDs – ibuprofen (Motrin) 600 – 800 mg/day, mefenamic acid (Ponstel) 500 mg/day, naproxen (Naprosyn) 500 mg/day, should be initiated 3 days before the onset of menses and continued through at least day two or three of menstrual flow. Re-evaluate effectiveness of this Tx plan after two or three cycles; if ineffective try a different class of NSAID, or prescribe an oral contraceptive (OC). Start with a low dose triphasic Ocs like ethinyl estradiol/levonorgestrel (Triphasic, Tri-leven, Lo/Ovral) 1 pill/day.
2) Secondary Dsymenorrhea: Keep the causes of secondary dysmenorrhea in mind before prescribing Tx. Relieve sx, and help the patient return to normal function ASAP. If the pain is structural in nature, consider Dx such as cervical or endometrial polyps, ovarian cysts, or tubo-ovarian abscess. Nonstructural causes include endometriosis, PID, and leiomyomas.
§ Ovarian cysts and cervical polyps: ovarian cysts <4 cm size, on US, can be Tx with NSAIDs and OCs. If cysts are >6 cm, refer to a gynecologist for further evaluation and possible laparoscopy to remove the cyst(s). Follow cysts of sizes between 4 – 6 cm carefully while treating them medically; if sx worsen refer these pts to gynecologist for probable laproscopy.
§ If cervical or endometrial polyps are the cause of pelvic pain, referral to a gynecologist.
§ Tubo-ovarian Abscess: fever, malaise, septic appearance, and exquisite pain on palpation of an adnexal mass or area of fullness denotes a medical emergency. The patient with TOA must be stabilized with IV ABX and fluids and referred to a gynecologist ASAP. If the pt is stable do an US to confirm your Dx.
§ Pelvic Inflammatory Disease: PID is characterized by fever, malaise, purulent vaginal DC, and exquisite tenderness on palpation of the pelvic organs. OP Tx. If patient is septic, start IV fluids and ABX and refer to gynecologist ASAP. PID is a serious disease and a prompt Dx is warranted for appropriate and early Tx, because PID is a leading cause of sterility in young women.
§ Endometriosis: It can be initially managed by the family physician with OCs and NSAIDs. When it is not successful, it is appropriate to refer the patient to the gynecologist for laproscopic evaluation and possible ablation of lesions as well as consideration of medical management such as danazol and GnRH agonists.
Premenstrual Syndrome:
I. Pathophysiology: PMS is a constellation of physical, emotional, and/or behavioral sx that occur during the 2nd half of the menstrual cycle (the luteal phase), which is under the influence of progesterone. It occurs approximately 7 – 10 days before the menses, with resolution of sx soon after flow begins. Pts with PMS must be sx free during the 1st half of the menstrual period (the follicular phase). Women in their late 20s – 30s have high prevalence.
The nature and severity varies from cycle to cycle for a particular woman, and vary from woman to woman. Most common sx include emotional lability, anxiety, depression, fluid retention, edema, craving for certain foods (primarily salty and chocolate foods), and pelvic or abdominal pain of variable intensity. The Dx is one of exclusion. Other conditions like MDD, anxiety d/o, dysmenorrhea, ovulation pain (Mittelschmerz), TOA, and endometriosis must be ruled out before making the presumed Dx of PMS. PMS is diagnosed only when the sx interfere with occupational and social functioning of the woman.
II. Clinical Evaluation: inquire about fever, pain at the time of ovulation (Mittelschmerz), fevers, malaise, and purulent cervical or vaginal DC. If none are present consider Dx PMS, and inquire regarding variation of sx during past cycles, past pregnancies, and post-partum periods, and any past psychiatric Tx. No laboratory or imaging tests confirm the Dx. Chart the sx, which should be 3 x more during the luteal phase, than follicular phase.
III. Management: Educational and support measures are central to the management of PMS and should be offered initially. If these fail, Tx with vitamin B6 throughout the month, NSAIDs given for 10 days preceding menses and for the first 2 days of the menses, and Prozac 20 mg PO qd.
Abnormal Uterine Bleeding
I. Pathophysiology: Normal uterine bleeding in a child bearing woman last 2 – 6 days with a blood loss of 20 – 70 ml, at intervals of 21 – 35 days. Flow lasting >7 days, blood loss >75 ml, or irregular menses <21 or >35 days are considered to be abnormal bleeding patterns. The following descriptions of abnormal bleeding must be known in order to communicate better among professionals:
A. Hypermenorrhea: heavy or prolonged bleeding.
1) Menorrhagia: prolonged (>7 days) or excessive uterine bleeding (>75 ml) occurring at regular intervals.
2) Polymenorrhea: uterine bleeding occurring at regular intervals of less than 21 days.
3) Metrorrhagia (intermenstrual bleeding): irregular uterine bleeding occurring at menstrual cycle, the amount being variable.
4) Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals.
B. Hypomenorrhea: scanty periods
1) Oligomenorrhea: uterine bleeding in which the interval between bleeding episodes varies from 35 days to 6 months.
C. Amenorrhea: no uterine bleeding for at least 6 months
D. Dysfunctional uterine bleeding (DUB): abnormal uterine bleeding whose etiology is hormonal; it accounts for 80% of cases of menorrhagia.
1) There are 5 type of hormonal dysfunction associated with DUB:
(a) Progesterone and estrogen withdrawal bleeding : normal mechanism for bleeding in the normal menstrual cycle, in perimenopausal patients who take cyclic HRT, and in patients taking OCs.
(b) Estrogen withdrawal bleeding : occurs from destruction of ovaries with radiation therapy, from oophorectomy, and when estrogen replacement therapy is only taken for 25 days of the month. Also cause of midcycle spotting in an ovulating patient, because the estrogen level drops slightly just before ovulation.
(c) Progesterone withdrawal bleeding: occurs whenever progestins are initiated and then stopped, as in progestin challenge test for Dxtic purposes.
(d) Estrogen breakthrough bleeding: Use of low-dose OCs may result in prolonged light bleeding because the amount of estrogen is insufficient to build up a stable endometrial lining, whereas high estrogen states, build up excessively thick endometrial lining, resulting in heavy building.
(e) Progesterone breakthrough bleeding: less common and usually results from continuous administration of progestins alone for contraception (the “mini-pill” or Depo-Provera injections). It can also occur with the use of OCs that contain higher proportion of progestin-to-estrogen component.
II. Etiology of DUB is related to reproductive phase of the patient.
A. In post-puberty girls who have recently reached puberty, are not sexually active, and whose menstrual cycles are not yet regular, have anovulatory cycles, and thereby irregular menses; full maturation of the hypothalamic-pituitary-ovary axis usually occurs within 18 months of menarche.
B. Post-pubertal women who do not yet have perimenopausal menstrual irregularities often get DUB due to hormonal contraception or may be anovulatory as a result of polycystic ovary syndrome, stress, weight change, or exercise.
C. Perimenopausal women have DUB as a result of anovulatory cycles or short ovulatory cycles.
D. If the pt is <30 years of age and sexually active with DUB, consider pregnancy related conditions such as spontaneous abortion or placental previa, and if there is abdominal pain, consider ectopic pregnancy and abruptio placenta. Also consider STDs, especially in women with multiple partners and those who have unprotected intercourse.
E. Women >40 years of age with DUB, consider endometrial CA. Other risk factors of endometrial CA include: chronic anovulation, obesity, HTN, DM, and exposure to unopposed estrogen.
III. Clinical Evaluation
A. Hx: When a woman has abnormal uterine bleeding, the physician has to first determine two things:
B. Determine the amount and chronicity of menstrual or intermenstrual bleeding
C. Determine whether the bleeding is ovulatory or anovulatory.
D. Do a PE exam, US, lab. tests.
E. Ovulatory bleeding occurs at regular intervals and is preceded by premenstrual sx like breast tenderness, water weight gain, mood swings, or abdominal cramps. Menorrhagia and intermenstrual bleeding occurs.
F. Anovulatory bleeding is characterized by prolonged bleeding that occurs at irregular intervals and usually follows several months of amenorrhea. Metrorrhagia and polymenorrhea occurs.
G. Obtain a screening hx for the major causes of menorrhagia:
(a) Bleeding d/o: Does the pt has bleeding problems with dental extractions, FHx of von Willebrand’s, heavy bleeding since menarche requiring blood transfusions (coagulopathies), immune thrombocytopenic purpura, hypothyroidism, uterine fibroids or endometriosis, medications (aspirin, coumadin).
IV. PE: check for
A. Thyroid disease: palpable thyroid
B. Bleeding d/o: ecchymoses, bruising, petechiae, palpable tender liver, jaundice
C. Pelvic examination: enlarged uterus (pregnancy, uterine malignancy, or fibroids, cervical polyps, cervicitis, adenexal tenderness.
V. Laboratory Tests:
A. Women over 40 with abnormal uterine bleeding should have an endometrial Bx.
B. Pap smear
C. CBC, PT, PTT,
D. TSH, Sr. prolactin, androgen studies (for women who have chronic anovulation >6 mo)
E. TVU and Dxtic hysteroscopy
F. Pts with endometrial thickness of >4 mm must have endometrial Bx.
VI. Management:
A. In a pt who present with c/o abnormal uterine bleeding, first determine the bleeding pattern: ovulatory or anovulatory.
1) If ovulatory pattern: consider anemia, hypothyroidism, coagulopathies, structural lesions (fibroids), and medications such as aspirin, warfarin.
(a) If no abnormalities are discovered, reassure and Tx with OCs or NSAIDs. OCs regulate her abnormal bleeding pattern.
(b) If pt has iron deficiency anemia but otherwise normal evaluation, treat with OCs and NSAIDs. If she does not respond to this treatment within 3 months, consider referral to a gynecologist. If there is structural lesion in a pt with severe anemia: refer to a gynecologist.
2) If pt is having anovulatory bleeding, perform a focused Hx and PE and appropriate laboratory studies to rule out pregnancy, hypothyroidism, anemia, prolactinomas, and structural lesions such as leiomyomas.
B. If no abnormalities are found, the pt has DUB. Tx is based on the age of the woman and presence of risk factors for endometrial CA..
C. If the woman is <35 years of age with no risk factors for endometrial CA: Tx with OCs or cyclic oral progesterone. The medication can be discontinued if the pt resumes normal cycles after 3 – 6 mos of Tx. If pt continues to have abnormal uterine bleeding, resume Tx and consider referral to a gynecologist.
D. If pt is >35 year of age with risk factors of endometrial CA (chronic anovulation, obesity, HTN, DM), do endometrial Bx. If the reports is negative, Tx with OCs, oral progesterone, or HRT. If Bx is positive, refer pt to gynecologist
E. If pt has intermenstrual (ovulatory) bleeding, perform a urine pregnancy test. If positive, the Dx of ectopic pregnancy an threatened abortion need to be considered and appropriately managed. If it is negative, further management is with OCs.
F. If pt is taking OCs and has abnormal uterine bleeding, advise additional contraception methods and to take OCs daily and at approximately the same time each day, and ask about medications that can result in breakthrough bleeding: ABX.
1) If this fails, consider changing her OC formulation.
(a) If pt continues to have intermenstrual bleeding after 2 cycles of the new OC formulation, refer her to a gynecologist for further evaluation.
G. If pt is not taking OCs, evaluate for structural lesions such as cervicitis, cervical polyps or CA, vaginal lacerations, and fibroids.